Benefact Pharmacy

Pharmacy Benefact
A B U L L E T I N F O R P H A R M A C Y S E R V I C E P R O V I D E R S F R O M A L B E R TA B LU E C R O S S
Number 492 • November 2014
Submit before you call:
real-time direct bill authorization available for
Group 66 over 100 days’ supply
As a reminder, you no longer need to call to receive authorization for over 100 days’ supply. Instead, simply submit your
direct bill claim, and you will receive a rejection message if the claim cannot be submitted electronically. When seeking
authorization for an over 100 days’ supply, please follow the steps outlined below.
Note: claim submissions for an over 100 days’ supply should be sent seven days prior to the member’s departure date.
Step 1:
Direct bill
Submit claim for
over 100 days’ supply.
1. Group 66 member presents a
prescription(s) for a greater than
100 day’ supply.
2. Submit real-time claim for required
medications in excess of a 100 days’
supply.
3. The claim will be adjudicated and
accepted if the member is eligible for
a supply of greater than 100 days (to
a maximum of 200 days). No further
action required.
Step 2:
Step 3:
Phone
FAX
First, submit all claims over 100
days’ supply for real-time direct
bill authorization.
Only in the circumstances listed below
should you contact Alberta Blue Cross for
authorization of an over 100 days’ supply.
1. Member has Non-Group coverage
(Group 1 coverage). All requests for
over 100 days’ supply for members
with Non-Group coverage require a
phone call to Alberta Blue Cross for
over 100 days’ supply.
4. Claim is rejected with response code:
SD: “Maximum days’ supply allowed
is X.” Days’ supply exceeds quantity
authorized.
2. Member has coordination of benefits
(COB)
5. Resubmit the claim after adjusting
the quantity to “X” days as indicated
in the SD response code. Claim is
adjudicated and accepted according
to the member’s coverage. No further
action required.
4. If packaging of medications doesn’t
allow for the drug to be dispensed
in the amount of the days’ supply
requested. (such as didrocal kits,
insulins or inhalers).
6. Claim is rejected with response code:
D9: “Call Adjudicator.”
Authorization may be eligible but
requires the pharmacy provider
to contact Alberta Blue Cross for
consideration of approval. In this case,
see step 2.
3. Product dispensed is Narcotic/
controlled drug benefits.
5. Claim rejected with response code D9:
“Call Adjudicator.”
6. Claim is rejected with response code:
KN: “Day supply limit for period
exceeded”. The days supply requested
is greater than the approved Special
Authorization period.
If submitting real-time claims or phoning
is not an option, you may fax the
Alberta Health Over 100 Days’ Supply
Authorization Request form to Alberta
Blue Cross. The form is attached and may
also be printed from the Alberta Blue Cross
web site at http://www.ab.bluecross/
providers/pharmacy-home.php.
Please fax the request at least seven days
prior to the member’s departure date to
allow sufficient time for review. Alberta
Blue Cross will provide the pharmacy an
authorization number at least five days
prior to departure for eligible members.
When phoning, have the following
information ready:
• Pharmacy licence number
• Member’s first and last name
• Date of birth
• Alberta Blue Cross ID number
• Personal Health Number (PHN)
• DIN
• Quantity requested
• Days’ supply
continued on page 2
Criteria for approval of Group 66 over 100
days’ supply
•
Available only for members leaving the province for more than 100 days.
•
One authorization per benefit period (July 1 to June 30).
•
Up to a maximum of 200 days’ supply, considering quantities on hand.
•
Plan members must be stabilized on their medication.
•
Consecutive authorizations will not be approved.
•
Drug benefits requiring Special Authorization that are limited to a maximum of less than 100 days’ supply (such as Enbrel
and Humira, etc.) will not be approved. Please contact Alberta Blue Cross for consideration of these drug benefits beyond
the maximum days’ supply as per the existing Special Authorization criteria.
•
Authorizations for palliative care members will not be approved.
•
Authorizations for members with less than 90 days’ coverage prior to the request for over 100 days’ supply will not be
approved.
Q&A
Q: Can members with Alberta Blue Cross employer Group and Individual Product coverage receive a greater than
100 days’ supply authorization?
A: On an exception bases, these members may be eligible for a greater than 100 days’ supply authorization. Please contact
Alberta Blue Cross for consideration an authorization.
Q: When is an authorization number issued for approval of a greater than 100 days’ supply request?
A: When you are required to call or fax for greater than 100 days’ supply and the request is approved, you will be issued an
authorization number for claims submission and documentation purposes.
Q: If I submit a claim for greater than 100 days’ supply and it is accepted, do I have to phone Alberta Blue Cross for an
authorization number?
A: No. Acceptance of the claim is validation that authorization for a greater than 100 days’ supply has been granted.
When you have questions:
For assistance with benefit or claim inquiries, please contact an Alberta Blue Cross Pharmacy Services Provider Relations
call centre representative at:
780-498-8370 (Edmonton and area) • 403-294-4041 (Calgary and area) • 1-800-361-9632 (toll free)
FAX 780-498-8406 (Edmonton and area) • FAX 1-877-305-9911 (toll free)
®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue
Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits
Corporation for use in operating the Alberta Blue Cross Plan. ABC 82320.492 2014/11
Alberta Health Over 100 Days’ Supply
Authorization Request form
Please fax this request form to Alberta Blue Cross: 780-498-3528 and toll-free 1-877-498-3528.
Pharmacy Information:
Pharmacy License Number:
Contact Name:
Phone:
Fax:
At the request of the plan participant named belowwho is travelling out of province on the dates shownthis
pharmacy is requesting authorization to dispense more than 100 days' supply of the listed medications.
Drug benefits requiring Special Authorization that are limited to a maximum 30 day supply (for example, Enbrel or
Humira) are not eligible for requests over 100 days’ supply. Please contact Alberta Blue Cross Pharmacy Services
at 780-498-8370 (Edmonton and area), 403-294-4041 (Calgary and area) or 1-800-361-9632 (toll free) for
consideration of authorization of these drug benefits beyond the maximum days supply as per the current special
authorization criteria.
Participant Information:
ID Number:
First Name:
Last Name:
Departure Date:
Medication name
Date of Birth (yyyy/mm/dd)
Group 1
Group 66
Return Date:
DIN
Quantity
requested
Quantity Auth
(Alberta Blue Cross use only)
Days Request
Days Auth
(Alberta Blue Cross use only)
Amounts authorized may vary from amounts requested due to the quantity the patient has on hand and days’ supply
limitations of some medications.
•
•
Please submit requests at least seven business days prior to patient's departure date; this allows sufficient time for review.
Alberta Blue Cross will provide the pharmacy with an authorization number five business days prior to departure for eligible participants.
Pharmacy comments:
To be completed by Alberta Blue Cross:
Date effective:
ABC 31151 2014/10
Date expired:
Authorization number:
Authorized by: